Mood disorders
1. Depressive Illness (Unipolar Depression)
Introduction:
Very common, rank 4th as a cause of disability worldwide, projected to rank 2nd by 2020. Although effective treatments are available, depression often goes undiagnosed and untreated, often regarded by both patients and physicians as understandable.
Mild depression has a significant morbidity and mortality. Suicide is the leading cause of death in person 20-35 yrs; high percentage (up to 50%) is depression.
Depression disorder also contributes to higher morbidity and mortality when associated with other physical disorders (e.g. MI) and its successful diagnosis and treatment has been shown to improve both medical and surgical outcomes.
There remains an innate reluctance to consider pharmacological interventions for emotional problems, despite overwhelming evidence of efficacy. Also widespread concern that drugs which improve mood must be addictive, despite evidence to the contrary.
Non compliance remains the major reason for treatment failure and often underestimated (up to 40% of treatment failure due to non-compliance).
Diagnosis:
Slight difference between the ICD-10 and the DSM-IV, however the core symptoms are almost identical:
Somatic symptoms, also called ‘biological’, ‘melancholic’ or ‘vital’
Psychotic Symptoms:
Severity:
Mild, moderate or severe
Subtypes:
? Melancholic or with somatic symptoms
? With psychotic symptoms
? Under ‘other depressive episodes’:
Indirect presentation
Epidemiology:
Prevalence 2-5%
Lifetime rate 10-20%
Sex Ratio M:F 1:2
It is increasing.
Aetiology:
(Bio-Psycho-Social approach / 3Ps Predisposing, Precipitating and Perpetuating)
1. Biological and genetic factors:
Lack of Monoamines (Serotonin, Noradrenalin, and possibly Dopamine)
Antidepressant work by increasing the above. SSRI (serotonin reuptake inhibitors e.g. Prozac, Cipralex. TCA (old antidepressant which has severe side effects including cardiac) prevent reuptake of both serotonin and noradrenalin. Other new medications such as Effexor work on all three (low dose ?serotonin, moderate dose? noradrenalin then high dose? dopamine).
Above is oversimplification and other transmitters such as GABA and peptide (e.g vasopressin) are involved. There is also link with abnormalities in regulation of many hormones (stress hormones) such as Cortisol and the Hypothalamic-pituitary-adrenal (HPA) axis. New generation antidepressants (in the making) are to target all of the above.
Twin and family studies have shown that there is a genetic basis to many cases of depression; hence a family history is a significant risk for depression
2. Psychological and social factors:
There is strong evidence that psychological factors (e.g. maternal deprivation or other childhood loss) may predispose to depression. Type of personality is also a risk (obsessive compulsive Personality).Life events such as marital separation, job loss and other stresses also play a role.
Other social risk factors include being at home with young children, unemployment, and lack of close confidants
Differential Diagnosis:
THEREFORE ALWAYS EXCLUDE ORGANICITY AS A PRIMARY CAUSE FOR DEPRESSION.
Course & Prognosis:
Depressive episodes vary from 4-30 wks for mild-moderate cases, to an average of about 6 months for severe cases (25% will last up to 1 yr)
The majority of patients experiencing a depressive episode will have further episodes later in life (risk of recurrence is 30% at 10 yrs, 60% at 20 yrs).Recurrence is greater when there are residual symptoms after remission.
There are good evidence that modern antidepressant treatment impact significantly upon the above, reducing the length of depressive episodes; and if treatment is given long term, the incidence of residual symptoms is less, there are fewer recurrent episodes, and chronicity may be as low as 4%
Mortality suicide 15% (severe) especially requiring hospital admission, overall rate of death is higher than general population with other causes usually due to substance misuse, accidents, cardiovascular disease, respiratory infection and thyroid disorders.
Good prognostic factors: Acute onset, ‘somatic symptoms’. Earlier age of onset
Poor Prognostic Factors: Insidious onset, elderly, residual symptoms, neuroticism, low self confidence, comorbidity (physical or psychiatric. personality disorder), lack of social support
Management & Treatment:
? History
? MSE (Mental State Examination)
? Physical Examination
? Investigations: Standard test: FBC, ESR, B12/Folate, U&E, LFT, TFT, Glucose, And MSU. Others: EEG, CT/MRI, HIV testing etc (all depends on the history and physical examination.
?Treatment:
1. Antidepressent: effective in 65-75% of patients. All currently available antidepressant work by increasing the availability of the monoamines (5HT, NA & DA). Many classes are available:
2. Psychotherapy:
CBT (Cognitive-Behavioural Therapy)
IPT (Interpersonal Therapy)
Psychodynamic (Psychoanalysis): lacks evidence based support.
3. Combination of the above may act synergistically
4. Augmentation (Evidence for lithium and mood stabilisers).
5. ECT: May be considered as first-line therapy when there are severe biological features (significant weight loss) or marked aggression, retardation or suicide risk, psychotic features are prominent.. Consent needed, main risk due to anaesthesia, safe, no aboslolue contraindication.
6. Psychosurgery only in exceptional circumstances when all other fails. Employ stereo tactic method using MRI.
7. Others: Light Therapy, rTMS (repetitive transcranial magnetic stimulation, Magneto-Convulsion Therapy (MCT), Vagus Nerve Stimulation(VNS)
2. Bipolar Illness (Manic-depression):
Diagnosis:
Mania (Bipolar I): A distinct period of abnormally and persistently elevated, expansive, or irritable mood, with 3 (or more) symptoms. lasting 1 week or less if admission is required.
Clinical Features:
Psychotic symptoms:
Hypomania (BPII): 4 days and symptoms less severe and does not interfere with social or occupational function
Epidemiology:
Life time prevalence 3-1.5%
M=F (except Rapid Cycling i.e. more than 4 episodes a year)
Age mean 21yrs, males earlier than females.
Aetiology:
(Bio-Psycho-Social-/ 3Ps Predisposing, Precipitating and Perpetuating)
(Patient must have the genetic predisposability)
Genetic 1st degree relatives are more likely to develop the condition (10-15%). Children of a parent with bipolar disorder have 50% chance of developing a psychiatric disorder (genetic liability appears shared for schizophrenia, schizoaffective, and Bipolarity).
MZ twins 33-90%, DZ twins 25%
Neurotransmitters NA, DA, 5HT and glutamine
HPA axis stress hormones.
Differential Diagnosis:
As in depression exclude organicity (secondary mania)
Medication that may induce mania:
Antidepressant
Other psychotropic medications
Anti Parkinson medications
Cardiovascular medications
Respiratory drugs
Anti infection
Analgesic
Gastrointestinal drugs
Steroids
Others: interferons, cyclosporine, baclofen
Course & Prognosis:
Extremely variable.1st episodes may be hypomanic, manic, mixed or depressive. This may be followed by many years without further episodes, but the length of time between subsequent episodes may begin to narrow. There is often a 5-10 years interval between age of onset and treatment. Depression is much more common to be first, mania can present even at later life (>50).
Mortality and morbidity rates are high, in term of lost work, productivity, effect on marriage (much higher divorce rate). Attempted suicide up to 40% and completed up to 10%
Within the first 2 years of 1st episode, 50% will experience another episode.
Poor prognostic factors: Poor compliance, Unemployment, substance misuse, psychotic features, male, mixed state, rapid cycling.
Good prognostic factors: Mania episode of short duration, later age of onset, good response treatment, and few comorbidity physical problems.
Management & Treatment:
(Bio-psycho-social approach again!!)
Same as depression in term of assessment
?First line treatment:
Lithium, Antipsychotic, ECT, BDZ (for acute episode).
?Second line:
Anticonvulsant: Valproate and Carbamazepine
?Psychotherapeutic interventions:
Most patients will struggle with some of the following issues:
Some selected intervention:
Cognitive Behavioural Therapy (CBT) time limited, with specific aims: educate the patient about bipolar disorder and its treatment, teach cognitive behavioural skills for coping with psychosocial stressors and associated problems, facilitate compliance with treatment and monitor the occurrence of symptoms (relapse signature)
Family Therapy
Support Groups
References
.1. Stevens L, Rodin I. Psychiatry: An illustrated colour text, Churchill Livingstone 2001
•2. Steple D. Oxford Handbook of Psychiatry, Oxford University Press, 2006
•3. Guthrie E & Creed F. Seminars in Liaison Psychiatry. Royal college of Psychiatrist 2007
•4. World Health Organization (WHO). ICD-10 Classification of mental and behavioural disorders. Churchill Livingstone
•5. American Psychiatric Association (APA). DSM-IV-TR. Fourth Edition Text Revision. APA Publication
•6. King D. Seminars in clinical psychopharmacology. Second Edition 2004. Royal College of Psychiatrists
